New Insights on the Road to Zero

A

can undo everything

Why communications?

The IMB reiterated the way forward in

2013… We recommend that the Programme urgently construct and implement a plan to correct its crippling

under-emphasis on social mobilization and communications.

This should address :

The need to rehabilitate the reputation of the vaccine

in places where it has fallen into disrepute;

To elevate the social mobilization networks to excellent performance;

And to bring substantially more communications

expertise to the table in the Programme’s key strategic forums, including partnership, headquarters

and TAGs/ERCs.

“

“

Creating points of access

The terrains are unique, but common hazards emerge

We began to explore trust between the polio programme and caregivers…

Trust in the frontline worker

Trust in the GPEI programme

Trust in the OPV vaccine

To understand underlying reasons for refusal and inaccessibility….

And recognizing the need to consider the broader dynamics influencing vaccine uptake

To reach the last remaining children, we have to consider the larger networks around them

We’ve Expanded Our Expertise On All Levels From 6,648 to 13,202 Social Mobilizers

Nigeria 2,153 to 8,602

Pakistan 1,059 to 1,638

Afghanistan 1,694 to 2,892

Scaled up UNICEF HQ

May 2013: 19 posts, 32% recruited

May 2014 24 posts, 92% recruited

Communications: From 3 to 8 staff + experts in storytelling, innovation and knowledge management

And scaled up external expertise

Over 30 Institutions brought on board with Long Term Partnership Agreements Partnerships with Islamic Institutions and Leaders through the Islamic Advisory Group Over 40 CDC-supported STOP volunteers

McCann Health Weber Shandwick TRF

Harvard University

The Manoff Group ADCC Lapis Comminit

BBC Media Action Seed Scientific Equal Access

Johns Hopkins Anthrologica Orecomm Lapis

Thoughtworks PMC Intermedia

GWU JHU Drexel U

Comm4Dev M&D WPP

PCI Media Impact Rainbarrel Thompson Nepal

Ipsos CSF Salvage

Ohio University

We've gotten far enough that refusals are no longer the biggest problem.

2.3%

1.9%

0.7%

1.6%

Refusals have been reduced by 60% in endemic high risk areas since January 2013…

Global Pakistan Nigeria Afghanistan

Source: Independent Monitoring Data; Polio Control Room Data Pakistan

With a 48% reduction in Afghanistan. A 70% reduction in Nigeria and an 80% reduction in Pakistan.

1.2%

0.6%

0.1% 0.6%

48% Reduced

70% Reduced

80% Reduced

60% Reduced

Global Pakistan Nigeria Afghanistan

Source: Independent Monitoring Data; Polio Control Room Data Pakistan

This reduction is real. Approval of OPV is high Caregivers in high risk areas who believe giving polio drops to their children is a good idea:

Mogadishu Nigeria Pakistan

96% 96% 98%

Source: Harvard Polling Data, representative of 5 High Risk States in Nigeria, 14 high risk districts in Pashtun communities of Pakistan; Mogadishu. Data does not include FATA or Borno

Better data give us new insights and improved strategies Numerous data collection methods include polling community perceptions* in: - Somalia - Pakistan - Nigeria - Afghanistan - DRC

* Polling is conducted in collaboration with Harvard University and local institutions

Innovations are helping us communicate faster and better

Pakistan Voice SMS using local

religious leaders’ voices

Nigeria Bluetooth video sharing

at the doorstep

Kandahar City Revision of entire

frontline team composition to increase

female workers and greater access to

households

Lebanon Digital mapping of all

service delivery entry points that can offer OPV to Syrian

and poor Lebanese population

The biggest problem: Getting to the remaining children

Note: 2013 average based on campaign data from April to December, aggregating high risk areas as follows: Afghanistan: 11 LPDs in the South; Nigeria: 10 High-Risk States; Pakistan: High Risk Provinces (Balochistan, FATA, KP, Punjab and Sindh).

Source: Independent Monitoring Data from Afghanistan and Nigeria; Control Room Data from Pakistan

Afghanistan Nigeria Pakistan

7.1%

4.6% 2.8%

1.9%

1.3%

1.1%

Other Reasons Not Available

And it’s not simply a matter of getting to their doorstep

Mis

sed

Chi

ldre

n (to

tal)

2014 Average

To reach zero, we must be ready to take two paths

The first path: Overcoming barriers to vaccinating remaining

children in accessible areas

We need to equip frontline workers to access households Caregiver’s perceptions of vaccinators

Nigeria Pakistan

Trusted ‘a great deal’

72% 61%

Vaccinators are ‘very knowledgeable’ 61% 52%

Care about children in their community 69% 53%

Are from outside the neighborhood 31% 24%

Source: Harvard Polling Data, representative of 6 High Risk States in Nigeria, 14 high risk districts in Pashtun communities of Pakistan

Approval is not a steady state. Hesitation can also endanger success.

Nigeria Pakistan

Think polio may be curable 29% 31%

Concerned their child will get polio 86% 31%

A child needs polio drops every time

69% 81%

Intend to give their child drops every time

68% 81%

Approve Always

Refuse Always

Approve Sometimes

The second path: Finding ways to reach children in insecure areas

We have a million reasons to solve this problem

1,000,000 Children are Chronically Missed Due To Inaccessibility

Refusal HH Not Visited Absence

Source: Independent Monitoring (coverage) and Security Monitoring (inaccessibility)

Inaccessibility

20,000 Inaccessible

Children

197,000 Inaccessible

Children


Children


Children

0.1 0.2 2.2 2.4 0.4 0.1 2.6

12

50

0.1 0.4 0.6 0.1 1.2 0.2

38

Borno FATA Afghanistan East Somalia (Figures in Percentages)

Source: Independent Monitoring (coverage) and Security Monitoring (inaccessibility)

How are so many children beyond our current reach?

Part of the explanation for not reaching children in Borno & FATA can be attributed to distrust…

Rumors about OPV

Distrust in the health system delivering OPV

Vaccinators are not • Trusted • Knowledgeable • Showing concern for children’s well-being • From the local community

1 2 3


Social support for OPV in Borno (% caregivers saying each influencer thinks giving OPV is a very good/somewhat good idea)

Reduced Support


Parent Health Worker Neighbors Community Leader

76% 46% 49% 88%

Grandparents

61%

And even when parents have high support for OPV, we can see that that’s not enough in these areas

We're making progress down both paths: Delivering strategies that overcome barriers in

accessible communities

And finding new ways to enter inaccessible areas

…and inaccessible ones.

Bauchi

BornoJigawa

Kaduna

Kano

Katsina

Kebbi

Sokoto

YobeZamfara

Security CompromisedVery Very High RiskVery High RiskNot ratedNon-HRA

All partners are providing additional services to communities in Kano, Borno & Yobe to strengthen trust

Bauchi

BornoJigawa

Kaduna

Kano

Katsina

Kebbi

Sokoto

YobeZamfara


Social Mobilizers


Bauchi

BornoJigawa

Kaduna

Kano

Katsina

Kebbi

Sokoto

YobeZamfara


CMAM Sites


Bauchi

BornoJigawa

Kaduna

Kano

Katsina

Kebbi

Sokoto

YobeZamfara


Health Camps


Shifting Gears in 2014: Enroute to Excellence

Anticipate and address refusals Anticipate and address refusals and

children unavailable, with revised operational strategies

A concerted focus on social mobilizers

A concerted focus on all frontline workers

Promote confidence in OPV Promote confidence in OPV and IPV

Collect social data

Systematically use social data in microplans and strategies

From To

Bare Minimum Excellence

Shifting Gears In 2014 Accessible (and all) areas

From To

Focus on individual behavior change for OPV

Focus on broader social support for immunization

Provide some polio plus activities A comprehensive, well-coordinated strategy to meet additional community demands

Vaccinate children in transit Understand, vaccinate and monitor all children traveling in and out of inaccessible areas

Promote GPEI success Promote confidence in local health services

Bare Minimum Excellence

Shifting Gears In 2014 Inaccessible areas

Waiting for access to open up Planting seeds of demand for vaccine uptake when services are provided

From To Outbreak response Emergency Preparedness in Red List

countries and Outbreak Response based on SOPs

Bare Minimum

Shifting Gears In 2014

Excellence

Outbreak Contexts

“The success of a disease eradication initiative... is largely dependent on the level of societal and political commitment to it from the beginning to the end.” – Walt Dowdle, ‘97

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